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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003060
Report Date: 10/25/2023
Date Signed: 10/25/2023 02:09:24 PM


Document Has Been Signed on 10/25/2023 02:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:WEST GLENN MANORFACILITY NUMBER:
306003060
ADMINISTRATOR:ROSARIO NAZARENOFACILITY TYPE:
740
ADDRESS:7242 WESTMINSTER BLVD.TELEPHONE:
(714) 898-2131
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:98CENSUS: 87DATE:
10/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Rosario Nazareno- Licensee/Adminstrator
Brian Nazareno- Assistant Adminstrator		TIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after delivering the findings into Complaint Control Number: 22-AS-20231020160710. The purpose of this subsequent visit was to issue a citation after observing a deficiency while conducting a complaint investigation in connection to the above-mentioned complaint. LPA explained the reason for the Case Management-Deficiencies visit to Licensee/Administrator (L/A) Rosario Nazareno.

During the complaint investigation, LPA observed that the facility did not report a medication error to the Department regarding Resident #1 (R1), therefore the preponderance of evidence standard has been met.

A deficiency is being cited as per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC809-D. L/A submitted the incident report to the Department on today's date during the visit.

An exit interview was conducted with Licensee/Administrator Rosario Nazareno and Assistant Administrator Brian Nazareno, and a copy of this report along with the LIC809-D, LIC811, and the appeal rights were provided at the end of the visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/25/2023 02:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: WEST GLENN MANOR
FACILITY NUMBER: 306003060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...
This requirement was not met as evidenced by:
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Administrator stated that they will submit the incident report regarding R1's medication error which was completed during the visit on today's visit.
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Based on LPA's observation, interviews, and record review, the facility did not submit R1's medication error report to the Department within 7 days of the event which poses a potential Personal, Health, and Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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